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How Administrative Burdens Push Down Children’s Public Healthcare Coverage

Study finds that certain policies hinder Medicaid and CHIP enrollment, disproportionally affecting disadvantaged populations

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Despite federally imposed restrictions on Medicaid eligibility, pre-pandemic enrollments declined after decades of increasing child access to public health insurance. A new study finds that policies described as “administrative burdens” hindered Medicaid and CHIP enrollment in the absence of significant changes in income eligibility thresholds or premiums.


The number of uninsured children in the U.S. has been declining for decades. But between 2016 and 2019, the trend reversed and the number of children without health insurance started rising.

Around this time, states introduced policies that can be described as "administrative burdens.” These policies resulted in significantly fewer children being covered, which, in turn, is likely to deteriorate their health outcomes.

Within six months of states implementing these policies, Medicaid and The Children's Health Insurance Program (CHIP) coverage decreased by an average of 6% for children, according to a study by healthcare economist and IPR associate Anna Chorniy with Princeton’s Janet Currie and University of Chicago’s Iris Arbogast. These negative effects continued up to two years after implementation, according to the researchers.

The study, which is set to be published in the American Journal of Health Economics, provides the first national, quantitative assessment of the role of administrative burdens in driving this drop in children’s health insurance coverage.

Administrative burdens are defined as the difficulties a person experiences—for example, not being able to comply with regulations in time to maintain eligibility or needing to provide excessive paperwork often or being disenrolled for the tiniest changes in their eligibility criteria such as a $100 change in their income—while interacting with government agencies.

These burdens disproportionally affected enrollment for disadvantaged populations: Children who are Hispanic, who have a parent who isn’t a U.S. citizen, or a parent who does not speak English well are between two and four times more affected.

“When states were prohibited from using their usual tools to adjust enrollments, like lowering income thresholds, they resorted to administrative burdens, which are inefficient and disproportionately affect the most vulnerable in already disadvantaged populations,” Chorniy said. “This explains a large portion of the increase in the number of uninsured children following decades of improving access to public health insurance.”

Chorniy and co-authors note that the increase for Hispanic children is separate from the public charge rule announced in September 2018 and enacted in October 2019. The term “public charge” dates back to the Immigration Act of 1882, which allowed the U.S. government to deny a U.S. visa to “any person unable to take care of himself or herself without becoming a public charge.”

In 2019, the Trump administration ruled that someone deemed a public charge could be denied entry into the United States or legal permanent residency. Prior to this, people could use public health insurance programs without being considered public charges. While the Biden administration repealed the rule, the researchers are concerned about its lingering effects. Chorniy noted it’s “disquieting to learn how much greater the effects are for more disadvantaged populations.”

Between 2014 and 2020, 15 states adopted either one or more of the following: more stringent and/or more frequent income and eligibility checks, or automatic disenrollment. While most states chose to enact either one or the other, Louisiana and Illinois were the only two states to adopt both. With double requirements, these states put “even more burden on their residents,” Chorniy explained.

Automatic disenrollment can cancel someone’s coverage without notice if the person has not responded within the requested time frame. In most cases, families don’t know they have lost coverage until they seek care.

“We would expect to see worsening of health outcomes due to reduced healthcare use, especially lack of timely, preventive care,” Chorniy said.

In March 2020, the federal Coronavirus Aid, Relief, and Economic Security (CARES) Act froze redeterminations of eligibility and suspended states’ Medicaid disenrollment during COVID-19, which grew the caseload by 20%. Now that the public health emergency has ended, more Americans are up for renewal, and more are being declared ineligible.

These post-pandemic renewals, Chorniy and co-authors offer, could mean that the administrative changes put in place prior to the pandemic “may have more bite,” meaning that the large numbers of disenrolled people like we are seeing in Illinois likely include eligible individuals. Plus, the huge backlog of cases may affect the timeliness and accuracy of re-enrollments. Twelve states, for example, have plans to terminate benefits without notice, according to the authors.

The authors also acknowledge existing evidence of “unofficial burdens” of enrollments, which they believe also contributed to the declines in coverage. These include agencies losing people’s paperwork, relaying misinformation, and making it hard to contact officials.

To stop the reversal of decades of progress on increasing children's healthcare coverage, Chorniy and her colleagues call on the federal government to:

  • extend how long a child can remain eligible,
  • reduce the stringency of income checks,
  • streamline eligibility across welfare programs, and
  • allow states to change eligibility thresholds.

All of these are in “a hope that they would stay away from official and unofficial administrative burdens,” she said.

Photo credit: iStock

Published: November 27, 2023.